Diagnosing Depression

Speaking to patients about depression is difficult because the word depression is used in different ways. One commonly speaks of being depressed when disappointed or frustrated. It is a universal feeling, immediately understood by everyone. Like joy, anger, longing and all the other named emotions, depression has been experienced by everyone. Used in this sense, depression is not abnormal. Although painful, It is an appropriate and inevitable response to circumstances. The feeling of depression will remit quickly if the circumstances of life change.

But there are conditions where the feeling of depression is part of a more prolonged disturbance of mind, which is manifested not just in sad feelings, but in certain typical thoughts and behavior. It is usually this intense state that impels someone to seek treatment. After an initial evaluation of depressed patients, I explain to them a little about different kinds of depression and why I think in their case I should prescribe medication—or not prescribe medication.

Before I report what I say to them, I must acknowledge that psychiatrists are not of one mind on this subject. For instance, anti-depressants are prescribed commonly (and I think, carelessly) in situations in which I would not. I will not presume to say that I am right, and they are wrong. There is little hard evidence about the way these drugs should be given. For instance, it was observed recently that many of the “scientific” studies that determined the value of these agents could not be replicated. On second look—long after these drugs were approved—some of these studies did not hold up. And yet, hundreds of millions of dollars were spent testing each of these drugs. Nevertheless, I think all psychiatrists, certainly including me, think these drugs do, in fact, work. But not all the time.

In appreciation of the fact that an initial course of an anti-depressant medication may not by itself cause a depression to remit completely, the American Psychiatric Association has produced an elaborate algorithm giving various choices of what to prescribe next. (Only about thirty to forty per cent of depressed patients respond within three weeks to a first anti-depressant, whichever anti-depressant is used.) Very briefly, the choices are to increase the dose of the first anti-depressant or add a second drug, and sometimes a third. That situation is remarkable in medicine because drugs found to augment the effect of antidepressants fall into four or five different classes: another anti-depressant, perhaps a tricyclic, an anti-psychotic, which is not used to counter a psychosis, but simply because it makes serotinergic agents like Prozac more effective, hormones, (thyroid) and a salt (lithium, used in smaller doses than it would be in bipolar disease.) Amphetamines, also, which are not a good treatment for depression given alone, have been used to augment the anti-depressant effects of other drugs. It is unusual, in my opinion, for treatment to fail in those depressions for which they are indicated. On the other hand, they will have only a placebo effect when given to other depressed individuals.

By the way, there are, perhaps, thirty anti-depressants in use—which is an indication that no one of them has been found to be obviously more effective than the others. They operate on different neurotransmitters—at least to a varying extent—but, nevertheless, all of them take at least three weeks to work no matter which class of anti-depressants they fall into. The particular drug the psychiatrist chooses is likely to depend on the potential side effects, which differ slightly from one drug to the next, on personal experience, and on what drugs are being promoted currently by one or another drug company.

With those caveats, this is us what I tell the depressed patients who find their way to my office:

“For purposes of talking about depression, I want to distinguish three different kinds of depression. Some people are always a little depressed. They have felt that way since they were young. They tend to have low self-esteem. They think they are not as attractive as they should be, or bright, or good in any other way. They do not perform as well as they should. They feel guilty in situations that others do not. They tend not to be assertive, because they do not think they deserve what others have; and they expect a bad result if they do reach out to others. That sort of depression reflects a point of view—about themselves and about the world. Such individuals may become pessimistic and bitter.

“These are learned attitudes, and, for the individual to give them up, they must be unlearned. The depression responds over a long period of time to psychotherapy and not to drugs. Maybe everyone has a little of this sort of depression.

“People can become profoundly depressed in the face of a serious loss—the death of someone very close, being abandoned or jilted by a lover, losing a valuable job and, sometimes, developing a serious illness. These are all losses of some sort. Someone who has been jilted, for example, can become so seriously depressed that that person may be considering suicide. Some people do kill themselves. Given the nature of a psychiatric practice today, such a seriously disturbed person presenting in a psychiatrist’s office will be given anti-depressants; but they are not likely to work. What these patients are experiencing is a kind of exaggerated grief. Like other forms of grief, it will get better with time. No one feels like killing himself/herself six months after being jilted. The proper treatment is a closely supervised supportive psychotherapy.

“If the patient does what is necessary (when possible) to redress a loss, the condition will go away relatively quickly. A lover jilted will feel better after about six months, usually, if he/she dates actively (not something that individual is going to want to do.) If the jilted lover mopes around the house indefinitely, recovery can take a year. These figures vary, of course, from one person to another. I don’t think anyone gets over a broken love affair entirely until there is someone else to take the place of the missing lover. Although drugs are given in this situation, their effect is likely to be limited to a placebo response.

“There is a third kind of depression.

“In every kind of depression, the affected individual is likely to be withdrawn and irritable, and unable to take pleasure in the usual activities that always had been pleasurable. Depressed people may develop vague physical symptoms. They tend to ruminate. But there is a third kind of depression that presents with additional symptoms. This is an illness. It tends to run in families and tends to start for the first time in late adolescence or in the twenties—although it can start at any time. Untreated, it is said to last about a year usually. It is likely to recur a number of times during the life of the patient. What sets this kind of depression off from the others is the presence of vegetative symptoms.

“First of all, the depressed person develops a very characteristic sleep disorder. Unless the depression is very severe, that person is likely to fall asleep readily, but will then wake up during the night, sometimes multiple times, feeling agitated and distressed –sometimes from a bad dream. Finally, the depressed person is likely to wake up too early—day after day and week after week—feeling very bad. The particular bad way he/she feels is different from one person to the next. Most people feel sad, but some do not. They may feel agitated, even panicky. That awful feeling fades somewhat during the course of the day; and the evenings may not be too bad. This is called a diurnal variation in mood.

“Another vegetative sign is of a depressed appetite, usually to the point of losing weight. Similarly, there is a loss of sexual interest.

“This third kind of depression requires treatment with the anti-depressant drugs.”

I do not go on to describe the depression that appears as part of a bipolar disease, and the so-called “atypical depression,” which is marked by excessive sleeping and eating. These conditions are real but somewhat less characteristic in presentation—and less common.

I think the distinction between kinds of depression drawn above is a good general guide to determining the appropriate treatment, and, in particular, the need for medication. (c) Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog

Very interesting and informing article! I can fully relate as I lived in agony for 40 years with anxiety, depression, panic attacks and a destroyed sense of self and identity. I wish that every person afflicted with these inner struggles to find peace and happiness and a way to control the emotions and behaviors associated with them. For those interested, I have a simple blog up with my experiences and my story, along with a few reviews of products/techniques that have helped me in my quest to find solutions. I sincerely want to spread the word about what helped me because after so many doctors and so many types of medicine I was at the point of believing nothing was ever going to help. I’m happy to share my story and hope it may help others! I know what facing death feels like my friends. My blog can be found at :

Very interesting and informing article! I can fully relate as I lived in agony for 40 years with anxiety, depression, panic attacks and a destroyed sense of self and identity. I wish that every person afflicted with these inner struggles to find peace and happiness and a way to control the emotions and behaviors associated with them. For those interested, I have a simple blog up with my experiences and my story, along with a few reviews of products/techniques that have helped me in my quest to find solutions. I sincerely want to spread the word about what helped me because after so many doctors and so many types of medicine I was at the point of believing nothing was ever going to help. I’m happy to share my story and hope it may help others! My blog can be found at :

Thanks for this incredibly approachable and understandable article. You have done a very nice job in breaking down use of the word "depression" into relatable pieces, and also in helping readers get a sense of what would be an appropriate conversation to have with their physician or mental health provider and expectation of the types of treatment that might be recommended. The Families for Depression Awareness "Coping with Stress and Depression" webinar can help people understand the differences and relationships among stress, anxiety, and depression. It's free and one hour long, accessible at http://www.familyaware.org/trainings/995-coping-with-stress-training.html. Thanks again for the useful article!

""First of all, the depressed person develops a very characteristic sleep disorder. Unless the depression is very severe, that person is likely to fall asleep readily, but will then wake up during the night, sometimes multiple times, feeling agitated and distressed –sometimes from a bad dream. Finally, the depressed person is likely to wake up too early—day after day and week after week—feeling very bad""

That could also be due to untreated sleep apnea or UARS which is causing people to wake up repeatedly throughout the night and end up feel very depressed due to not getting enough deep sleep. I think it should be mandatory that all physicians screen patients for sleep breathing disorders before putting them on psych meds that may greatly worsen instead of improve the situation. Particularly if they have issues with sleep.

Also, please google Barry Krakow, a sleep medicine physician, who has done alot of research in this area.

Going without sleep does not produce depression--although sometimes patients experience the problem in this way. Actually the sleeplessness is caused by the depression. Multiple studies in which patients are kept up arbitrarily support this fact. When this syndrome appears, anti-depressants are very effective in ameliorating the sleeplessness--which would not be true in cases of sleep apnea.
I agree that sleep apnea is under-diagnosed and should be suspected and tested for much more than it is.

Going without sleep does not produce depression--although sometimes patients experience the problem in this way. Actually the sleeplessness is caused by the depression. Multiple studies in which patients are kept up arbitrarily support this fact. When this syndrome appears, anti-depressants are very effective in ameliorating the sleeplessness--which would not be true in cases of sleep apnea.
I agree that sleep apnea is under-diagnosed and should be suspected and tested for much more than it is.

Dear Doctor,
That statement above is so ridiculous, it leaves me speechless. Almost. I have experienced, countless of times, insomnia induced depression. Yes, I suffer from depression, but I don't feel depressed every day. However, on days when I get only 4 hours of sleep, I am a mess. I feel down, am less able to cope, and cry easily. Interestingly enough, this also happens when I take Ambien or Klonopin for sleep and/or anxiety. Even though the meds let me sleep for 8 hours, the fact that they depress the Central Nervous System, only adds to the lethargic, vegetative depression that you describe.

Which brings me to your description of Depression number 3 and the manisfestation of Insomnia. I find your description highly inaccurate. As someone who has experienced both Depression #1 and #2 and #3, I can tell you that 90% of the time, Insomnia happens when going to bed. It is hard to fall asleep. But then I can sleep and sleep and sleep. Oversleeping and having a hard time getting up in the morning, still feeling fatigued after hours of sleep is a classic sign of depression. Your description needs to encompass this type of insomnia, to be comprehensive.

The Insomnia that you describe, the early morning waking, is something that I've experienced only as a side effect of antidepressants or withdrawal from antidepressants. Never as a symptom of depression itself. Perhaps some people do experience this, but you cannot discount the type of insomnia that I am describing, which a lot of people experience as well.

Next, I would like to say that I really liked your description of Depression #1 & #2. I realized that it was #1 coupled with multiple #2's that actually led to depression #3. The sensible thing to do, is address the source(s) that led to the depression in the first place.

Perhaps short term antidepressant use for the severely depressed might be a solution. But I wouldn't recommend it as a first course of treatment. Some of us develop severe side effects and protracted withdrawal from even short term antidepressant therapy. Also, as I now know, throwing antidepressants long term only serves to make Depression chronic, by severely down-regulating receptors that may take years to return to normal. Long term antidepressant use has also shown me that antidepressants severely reduce a person's coping mechanism. I have years of journals that clearly show how I was able to cope with multiple stressors, losses, and depression pre-antidepressants, and post-antidepressants.

Antidepressants and other Psychotropic medication has done so much harm to so many people, that one can say that it is a silent epidemic.

Hmm, you are viewing that from a psychiatric perspective. But according to Dr. Krakow, from the sleep medicine perspective, the relationship between insomnia and depression is more complex than previously thought. That is why it is important to screen people for sleep breathing disorders before you pile on medications and doom people to possible years of ineffective treatment that just makes the situation worse.

And here is a study about lack of sleep increasing psychological distress including depression.

There are many reasons why someone might not be getting enough sleep, including real medical issues. It's an unacceptably narrow view -- particularly from an MD -- that attributes every case of insomnia to depression.

Reflexively diagnosing "depression" and throwing psychiatric prescriptions at the problem may be a good way for a doctor to get rid of a complaining patient, but is not good medicine.

Furthermore, SSRIs destroy sleep architecture. Nothing like burning down the village to save it.

I enjoy reading this online magazine. But there are so many contradictory ( and categorical)articles maintaining that a particular mental disorder is an illness or alternatively cannot be an illness. I get the dizzy feeling of going around in circles when I read them.

I would like to quote from Gary Greenberg's book 'Manufacturing Depression'which was highly praised (deservedly) on this website.

'It would be nice to hear psychiatrists acknowledge in public that even though they've been telling people for two decades that they know what the underlying pathology of depression is, they really don't. But with the pathophysioloically based classification system that the book (A Research Agenda for DSM-V) says will solve this problem decades away, it's no wonder that the American Psychiatric Association wants to keep a tight lid on the proceedings.They don't want us to know that they're still working off that promissory note (of Kraepelin) until they're ready to put paid to it.'

It is possible that this problem of validity will never be solved.

So, tentative statements such as 'This maybe an illness' or simply 'We don't yet know if it is an illness' would make for more honest writing and easier reading.

Psychiatrists have related the effect of different anti-depressants on certain neurotransmitters to the possibility of depression being a disturbance of those neurotransmitters. Some clinicians have intimated that the metabolism of serotonin may be at fault somehow. I don't think many psychiatrists took this seriously, but if they did, they were wrong. We do not know the underlying physiological causes of any of the psychoses.But that is not to say we do not know that these conditions do, in fact, constitute illnesses.
Think of the infectious diseases, or the metabolic diseases such as diabetes. When they were first described, no one questioned that they were illnesses even though their underlying causes were not known (and in the case of certain metabolic disorders, are still not known.) Stop for a moment and think about how we make a judgement that someone is sick in the ordinary sense of that word:
1. They show abrupt changes of behavior and disturbances of physiological function that differ markedly from their previous functioning. (In the case of depression, the individual--previously well-- develops a characteristic sleeping disorder with early morning awakening, loses appetite to the point of losing as much as twenty to thirty pounds, feels worse in the morning for no obvious reason, and typically less bad in the evening,and loses interest in sex. This is sometimes a fatal illness since it provokes suicide in people who previously showed no discontent with their lives.)
2. They tend to develop a similar course from one person to the next.(In the case of depression, a relapsing and remitting course. Affected individuals, untreated, remain ill usually for the better part of a year and then recover spontaneously. These attacks can recur throughout life.)
3. A suggestion of a hereditary component, or other set of circumstances that set the affected person off from others around him.(There is an obviously familial connection.Depression is common among siblings and parents.)
I agree, nevertheless, as I indicate in my blogs, that some depressed persons are not suffering from this illness and should not be diagnosed with a major depression. Neither should they be prescribed drugs.

This is starting to look like a discussion about what we mean by illness!
Severe worry (and guilt)can cause abrupt changes in behaviour and disturbances of physiological function. It has been suggested that people can die of a broken heart! We could rename these states as illness but would that give any advantage to us?

As for suicide, I don't think that it is always an irrational act. To plan a suicide there must be some agency there so it seems strange to call it a fatal illness.
And it can often take a long time for the realisation of the cause of the depression to come.
Very often it is not one single event that has caused the episode. Single events can act a a trigger when they relate back to a background cause, and it often difficult to grasp that this background cause was traumatic. The only evidence that it was traumatic is the depressive reaction.
I think that human beings have a tremendous capacity to bury trauma and maybe that is an evolutionary advantage. This capacity allows people to continue living apparently normal lives until the trigger comes along and starts to unravel the complicated mechanism that allowed the trauma to be buried. Then this is seen as a depressive episode until the trauma can be reburied - or resolved in some way, if at all.

Some people can move on from the trauma and some can't. But it is not surprising that this process takes a simliar course from one person to the next. Perhaps this is the only way that humans can deal with trauma that was experienced and not resolved at the time.
As for hereditary components - one generation can pass the same traumatic experiences onto the next - have you read the famous poem by Philip Larkin?

If I understand the previous comments properly, the writer feels that the decision to kill oneself can sometimes be a rational and considered judgement, sometimes growing out of a hidden trauma. I would like to mention a frequent clinical experience that suggests that psychological causes do not always underlie such a desire. I have had a patient who made an unsuccessful, but serious, suicide attempt who then explained to me in cogent and calm terms his reasons. They centered, as they usually do, on family matters, concerns about finances, and a recent serious illness. For reasons that I have described here repeatedly, I gave the patient medicine.A month later the patient reported that he felt well, and was certainly not suicidal. His family reported that he was back to his old self. When I asked about the particular reasons he gave me for his act, He responded by saying they were real problems, but he was handling them by doing this thing and that.
Now imagine that dozens of patients come with exactly the same symptoms and pattern of response to drugs: is that not an argument for the suicidal urge being temporary and a response to transient circumstances (and,indeed, to an illness.)
This debate about depression is an echo of a previous debate in the 50s and 60s about the existence of mental illness. Thomas Szasz wrote a book called "The Myth of Mental Illness," and there were others who felt more or less similarly, including R.D. Laing, who wrote a book called "The Divided Self."
I thought their views were silly, and so I do not trust myself to report them here without caricaturing them. Read the books. But I am reminded of a court encounter I had back in those days that struck me as amusing at the time.
The patient involved had been admitted to a psychiatric hospital with an acute paranoid psychosis. Although unimproved he wished to be discharged.
New York State law requires that such a patient be given an opportunity in court to convince a judge that he is well enough to leave the hospital.During this man's court hearing, I testified that he was actively suicidal, and possibly dangerous to others, and that he required further hospitalization and treatment. The opposing psychiatrist, whom the patient had hired was evidently an acolyte of Szasz. He took the stand and testified that in his professional opinion, the patient was well and entitled to his freedom. The judge seemed genuinely interested in his opinion.
"You don't think his hearing voices is an indication of mental illness?" the judge asked.
"No," the psychiatrist replied.
"He threatened to hurt his neighbors for trying to poison him. Don't you think that was an indication of a mental illness?"
"No."
"He tried to throttle a stranger in the street for being part of a conspiracy. Wasn't that evidence for a mental illness?"
"No.
The judge, (catching on finally): "Don't you think there is such a thing as mental illness?"
"No."
"You can step down, doctor," the judge said turning away in disgust.
I suspect there are still some who would agree with that psychiatrist.

I have read a lot of Thomas Szasz and others who write in a similar vein and I have a lot of time for their views. I have also been around someone as a carer who had the extreme problems with paranoid psychosis.
The situation you describe seems still to be an argument about words. Refusing to describe some as not having an illness even when they are in the throes of very disturbing behaviour does not mean that you don't think that there is a very severe problem!
Sometimes sedation is the only answer but that is all it is.

But I wanted to make a point about the difference between describing a mental disorder of the mind/brain an illness and callng a disorder of some other part of the body an illness.
If I had a mental disorder and I was told to see it as an illness rather than an reaction to trauma then that would have a big impact on how I view myself. And consequently the treatment for it would have a big impact on how I view myself. This where the harm can be done. So there is a large moral dimension to the decision as to how one regards the problem. Do I want to see myself as diseased or traumatised? Do I want to see myself as a mental patient or not? And who makes this choice as to how I see myself? Does the doctor know me better than I know myself?

Conversely, if I had, say cancer , I would not care whether it was radiotherapy, chemotherapy or surgery, as long as it got the job done. It would not necessarily affect the way I see myself because, of course, the doctor knows my cancer better than I do. I can't even see it because the doctor can see the insides of my body in a way that I can't.
However the doctor can't see my mind better than I can. In a brain scan he can only see blood flowing but can only guess as to how the objective image is relating to my subjective experiences.

In conclusion, one of the hardest things to deal with in life is being seen in a way and that you can't recognise as being the real you and then being powerless to do anything about it. It is pernicious and can make a normal life impossible. So I think that describing mental illness as an illness like any other( although I don't think you said that exactly)is wrong. But I do recognise that some people would prefer the 'illness' status to the 'traumatised'status or even the 'bad' status but who chooses their status?